School nursing: New ways of working with children and young people during the Covid‐19 pandemic: A scoping review

Abstract Aim To examine how school nurse practice evolved as a result of the Covid‐19 pandemic. Design A scoping review of international literature, conducted and reported in line with Arksey and O'Malley's (2005) framework. Data Sources Searches were conducted in September 2021. Ten databases were searched: The British Nursing Database, CINAHL, Cochrane Library, Consumer Health Database, Health and Medicine, Nursing and Allied Health, Public Health, PsycINFO, PubMed and Web of Science. Relevant grey literature was identified through hand searching. Review Methods A minimum of three reviewers independently screened articles and two reviewers independently undertook data extraction, with any decisions made collaboratively with the wider team. Much of the literature was not empirical work and so it was not possible to apply a traditional quality appraisal framework. Results Searches identified 554 papers (after deduplication) which were screened against title and abstract. Following the full‐text review, 38 articles underwent data extraction and analysis. The review findings highlighted that school nurses adapted their practice to ensure they were able to continue providing their formal and informal school health offer to children, young people and their families and continued working closely with the multidisciplinary team. In addition, the expanded public health role generated by Covid‐19 for school nurses' work was considerable, multi‐layered and added to their routine workload. School nurses displayed resilience, adaptability and creativity in their response to delivering services during Covid‐19. Conclusion School nurses took on a leading public health role during the Covid‐19 pandemic. Some developments and practices were highlighted as beneficial to continue beyond the pandemic. However, formal evaluation is needed to identify which practices may merit integration into routine practice. Continued investment in staff and infrastructure will be essential to ensuring school nurses continue to expand their practice and influence as public health experts.


| INTRODUC TI ON
This review presents a global perspective on the responses of school nurses (SNs) to the public health challenges of the Covid-19 pandemic.
During the pandemic, SNs faced the challenge of delivering remote routine statutory and non-statutory services and multidisciplinary working, as well as an increased infection control and safeguarding role. This was alongside additional constraints on staffing through sickness and redeployment and personal additional caring and/or home-schooling responsibilities. Reports show that SNs responded positively and proactively to these demands, and there are many examples of SNs taking on new or expanded public health roles, as well as using creative and innovative practice to overcome barriers. This review brings these examples and evidence together from the literature to give an overview of new, adapted and extended practice, and the benefits and challenges of the changes required. Findings from this review highlight the specialist public health role of the SN. The review strengthens the evidence base regarding SN practice, which can in turn inform policy regarding the vital public health role of the SN, and be a resource for SNs regarding effective practice.

| BACKG ROU N D
The Covid-19 pandemic led to remote curriculum delivery for many children across the globe over a significant period of time.
This was followed by ongoing disrupted on-site schooling due to isolation requirements and/or sickness. SNs' informal and formal in-person contact with children, young people, their families and the multi-disciplinary team (MDT) was initially halted, and then interrupted with the ensuing changes in social contact guidance.
For SNs this has been a significant challenge for maintaining both universal and targeted support for children and young people (CYP) as usual modes of contact through school drop-in sessions, classroom activities and in-person professional meetings were no longer viable. As lockdown extended, and isolation and shielding became a regular occurrence, it became apparent that safeguarding CYP was also a significant public health issue as child protection concerns and referrals increased. Several reports highlighted the increased vulnerability of CYP during the mandated lockdown periods (Green, 2020;United Nations [UN] Women, 2020; Young Minds, 2021).
This review presents a synthesis of change in school nursing practice in the international literature as a result of Covid-19, lockdowns and decreased in-person contact. The review included all direct practice delivery changes. It also sought to specifically foreground change in practice that relates to SNs' safeguarding work with CYP, their families, and the MDT. A global perspective was taken to facilitate an understanding of how SNs across nations responded to challenges in practice incurred by the pandemic, and widen the learning landscape.

Impact
What problem did the study address?: School nurses play a key role in delivering routine services (statutory and non-statutory) to young people and their families, as well as working extensively with other professionals to support and safeguard children and young people. During the Covid-19 pandemic, it was necessary for school nurses to develop and evolve their practices to be able to continue to deliver their services.
However, there is little detail about the nature of these changes and if any may be of benefit to school nursing practice in the future.
What were the main findings?: During the pandemic, a range of innovative and adaptive practices were identified as being adopted by school nurses across the world to allow them to: i. continue providing their formal and informal school health offer to children, young people and their families, as well as continue working closely with other professionals and ii. carry out their expanded public health role.
Where and on whom will the research have an impact?: It is important to formally evidence the public health expertise of the school nurse. Further research and formal service evaluations (from both school nurses and children and family perspectives) of new school nursing practice which evolved as a result of Covid-19 are needed to identify those which may have value post-pandemic. Key stakeholders such as policy-makers and funders need to consider necessary investment in resources and infrastructure.

K E Y W O R D S
adolescent health, family care, health services research, literature review, public health nursing, school nursing 3 | THE RE VIE W

| Aim(s)
This review identified the ways in which SN practices evolved as a result of the Covid-19 pandemic. We documented how SNs worked with CYP and their families, the wider SN community and the MDT.
In doing so, we identify the benefits and challenges in SNs' new working practices. Recommendations are made to inform future practice in CYP's public health care; strengthen service delivery in the longer term; and inform policy going forward.

| Design
This review was registered with PROSPERO (CRD42021296878).
Throughout the design and conduct of the review, expert stakeholders (practising SNs, representatives of professional SN organizations) were consulted. The intention had been to undertake a systematic review to provide a quality appraisal of research evidence; however, due to the low number of empirical studies and wide range of includable grey literature, a scoping review was conducted, in line with Arksey and O'Malley's (2005) framework.
As there was limited literature focusing on the impact on vulnerable children, a broad definition of 'vulnerable' to encompass all children (in addition to those requiring mandatory support and monitoring) was adopted. This decision was made in consideration of the social, economic and psychological challenges incurred by Covid-19 which increased the vulnerability of all CYP (Young Minds, 2021). The review is reported in line with the PRISMA guidelines for scoping reviews (Tricco et al., 2018).

| Search methods
A broad initial search strategy was adopted due to an awareness that

| Search outcome
One thousand and thirteen references were identified from database searches (n = 997) and grey literature searches (n = 16). After deduplication five hundred and fifty-four references were included.
After screening by title and abstract, 93 records were assessed as eligible for full-text review (n = 82 database and n = 11 grey literature). We excluded those articles where a full-text version could not be retrieved (n = 2), leaving 91 records for full-text review, following which 38 articles were included (see Figure 1).

| Screening
One reviewer (GC) undertook an initial filter of duplicates. A minimum of three of the four reviewers (GC, JA, SB and DS) independently screened all titles and abstracts and then full-texts of the identified relevant publications. Disagreements were resolved through discussion between the reviewers. During this process, pragmatic decisions had to be made around certain issues that lacked clarity within the articles. These decisions were made collaboratively, with at least three reviewers being involved in all inclusion decisions. The software package Rayyan was used to record screening decisions and justifications (Ouzzani et al., 2016).
We initially sought to capture innovative practice with a specific focus on CYP. However, early engagement with the literature highlighted accounts of diverse adaptations and extensions of existing practice, as well as discussion of the benefits and challenges to SNs fulfilling their role within the constraints of the pandemic. We therefore felt it was important to maximize the opportunity to document the full extent of what SNs were doing in their work with CYP, families and their partnership relationships.

| Quality appraisal
Much of the available literature obtained through our searches was not empirical research, therefore it was not possible to apply a traditional quality appraisal framework.

| Data abstraction
Following initial familiarization with the literature during a parallel phase of the project (survey development), subheadings were chosen for data extraction based on (1) topics and issues that were prominent in the literature, (2) the content we thought to be most appropriate for meaningfully answering our research questions and (3) input from our steering committee. Once the final list of 38 includable articles was identified, the relevant data from each article were extracted onto an Excel spreadsheet. The data extraction form was piloted using a sub-sample of 20 articles to ensure it was easy to use, able to be interpreted consistently and captured all relevant information.
The data extraction headings were developed through a preliminary iterative process by the two data extractors (GC and DS) (see Table 1 for extraction headings). Data were extracted from each paper by one of two reviewers (GC or DS) with the other data extractor independently checking the extracted data for rigor and quality. Pragmatic decisions, uncertainties or disagreements were resolved through discussion between the independent reviewers in the first instance and wider project team as necessary.

| Synthesis
The headings of our data extraction sheet formed the framework for our synthesis. Two members of the team (GC and DS) independently grouped the extracted data to produce initial themes in the context of each heading (i.e. CYP, parents, etc.). Preliminary groupings were reviewed by another independent reviewer (SB) and extensively discussed (if necessary also with the wider team) until consensus was reached on the final themes. Kong (n = 2) and Sweden (n = 1). A range of publication types were represented: commentary (news, opinion pieces, editorials, etc.) (n = 27), case studies (n = 5), empirical research (n = 5) and a service review (n = 1). The included articles were published in 2022 (n = 1, originally published online in 2021), 2021 (n = 17), 2020 (n = 15) and some had no date (n = 5). See Table 1 for a summary of extracted data.
Technology was reported as beneficial for ongoing CYP consultations (Martinsson et al., 2021), communications (Lee et al., 2021;Unknown, 2020c) and engagement (Gingell & Spencer, n.d.;Unknown, 2020). Remote options saved time for some SNs, CYP and families, although others felt the increased frequency of contacts increased demand (Martinsson et al., 2021). CYP were reported to prefer virtual over face-to-face contacts (Tomkinson, n.d.), citing ease of discussing personal/sensitive issues, and young carers appreciated the support this provided (White, 2020b). Informal feedback highlighted that SNs were able to gain a more in-depth understanding of CYP's home situation and families' needs (Tomkinson, n.d.; Martinsson et al., 2021;White, 2020b). Though not ideal, conducting telephone assessments allowed CYP to share new concerns without delays to appointments (Unknown, 2020d).
However, virtual platforms could negatively impact the quality of SNs' conversations with CYP and families (Martinsson et al., 2021).
Video conferencing capabilities were necessary because some SNs felt telephone contacts were not sufficient (Gingell & Spencer, n.d.).
Also highlighted was the impact of digital poverty and resulting unequal access to services (White, 2021). Increased contact with students and families-often via virtual platforms-made additional demands on SNs' time (Martinsson et al., 2021;White, 2020b;Yip et al., 2020). Some reported a change in methods of communication to electronic only (Hoke et al., 2021).
Outdoor meetups (such as walk-and-talk sessions) were reportedly beneficial for a range of reasons including providing a 'physical connection' that was missing from virtual communication and being viewed positively by CYP and their families (Various, 2020b), resulting in improved attendance from CYP (Driscoll et al., 2021) and relaxed engagement (Evans, 2020). SNs also collaborated to distribute resources such as food and school supplies via drop-offs and deliveries (Combe, 2020a;Fauteux, 2021;Robarge, 2021;Robinson, 2021).
An extension to the timing of available services, such as routine vaccination access, was reported (White, 2021).

Education (CYP and families)
Virtual platforms were used to deliver routine health education (e.g.

Liaison with professionals
SNs used technology to facilitate engagement with professional networks, for example, virtually conducting Individual Education Planning, case conferences, core groups, child in need, disability support and safeguarding meetings (Flaherty, 2020;Unknown, n.d.;Unknown, 2020b;White, 2020b). Video conferencing was used for daily handovers, multi-agency meetings (Gingell & Spencer, n.d.) and to connect with social work managers (Unknown, n.d.).
Digitally delivered training for school-based colleagues around medical conditions was offered (White, 2020b).
Specific benefits of using technology for partnership work were reported as follows: the flexibility, time and travel cost savings, and greater attendance at meetings (Gingell & Spencer, n.d.). Virtual communication technology was also credited with providing new dimensions to relationship building and opened new communication channels, increasing the depth of discussions and improving the focus on children's needs (Unknown, n.d.). However, sometimes virtual platforms made it harder to discuss sensitive topics (Martinsson et al., 2021).
SNs offered emotional support to school staff (Lee et al., 2021), and similarly, peer meetings served as a way of providing mutual mental health support (Yip et al., 2020). SNs collaborated with their school-based colleagues to address new challenges, such as working with adjustment counsellors to improve student 'connectedness' (Marrapese et al., 2021), with teaching staff to identify students at risk of chronic absenteeism, and with school counsellors to produce resource lists to meet families' needs (Combe, 2020a). SNs interacted with their peers in new ways such as convening support groups (Fauteux, 2021); in some cases technology was used to facilitate this interaction, including online support groups (Cogan, 2021), providing mutual support (Combe, 2020b), and using apps to communicate informally to help overcome professional isolation (Lee et al., 2021).
A virtual 'town hall' (where points of interest, policy and legislation are discussed) was also used by SN organizations to connect with members (Combe, 2020a), and an annual conference transitioned to a virtual environment (Robarge, 2021). The use of technology was beneficial to communication with other professionals (Lee et al., 2021;Martinsson et al., 2021). Increased technological use and advancement such as the increased use of online systems resulted in services being 'safer, smoother and more efficient' and access to online systems assisted SNs in protecting the most vulnerable (White, 2021, p. 50).

| The expanded school health offer
This theme captures the ways in which the SN role expanded beyond its pre-pandemic remit, albeit in keeping with SNs' expertise as public health practitioners. This expanded role included a variety of novel and Covid-19-specific responsibilities.

Infection prevention and control: CYP and families
SNs took on numerous new Covid-19-specific roles and responsibilities with CYP. These included symptom monitoring and contact tracing (Combe, 2020b;Lee et al., 2021;Robinson, 2021;Sorg, 2020;Unknown, 2020a;Unknown, 2020b). Adaptations were made to existing daily practices, such as wearing personal protective equipment (PPE) for nebulizer administration (Barbee- Lee et al., 2021); physical setups were altered to create isolation areas; and SNs were required to enforce public health isolation and quarantine requirements (Barbee- Lee et al., 2021;Combe, 2020b;Ferrara, 2021;Lee et al., 2021;Robinson, 2021;Sorg, 2020). A telephone response service that parents (and schools) could contact for advice helped to relieve the pressure of calls to schools about Covid-19 (Various, 2020b). Additionally, SNs sent reminder emails to parents encouraging them to screen their children (Combe, 2020b). SNs educated parents and carers on issues relating to Covid-19 (Barbee- Lee et al., 2021;Traut, 2020), and communication with parents often increased for pandemic-related issues (Hoke et al., 2021;Lee et al., 2021;Unknown, 2020a;Yip et al., 2020).
Lesson plans to address Covid-19-related issues were developed (Booher, 2020). SNs produced pre-recorded informational videos predominantly focused on Covid-19 public health messaging (Combe, 2020a;White, 2020b;Yip et al., 2020), and sometimes shared these via social media platforms (Robarge, 2021;Various, 2020b). The videos had the reported benefit of providing advice and reassurance to CYP and parents (Various, 2020b). SNs were also involved in developing infographics to consolidate public health messages (Barbee- Lee et al., 2021).
There were challenges to implementing new infection prevention and control measures, such as having to socially distance from younger children who may experience affectional neglect (Martinsson et al., 2021). Similarly, PPE requirements created barriers to expressing empathy and 'building relationships with pupils' (Evans, 2020, p. 7), while limited space in some schools made social distancing difficult (Lee et al., 2021;Sorg, 2020). SNs were also tasked with ensuring students' compliance with hygiene practices, which was reported to be challenging for example, among younger children and those with intellectual disabilities (Lee et al., 2021). Further, SNs found themselves 'bearing the brunt' of negative social responses to Covid-19 regulations from parents (Cogan, 2021, p. 2) and teachers (Lee et al., 2021). The responsibility of ensuring families complied with guidelines, which carried implications for the wellbeing of the entire school community, was considerable (Robinson, 2021). SNs also faced the challenges of taking on new and extended roles with no additional training (Robinson, 2021;Yip et al., 2020), having to adapt practice in accordance with ever-changing guidelines and a lack of information (Combe, 2020b;Lee et al., 2021), and balancing professional judgement with official guidance (Combe, 2020b) and school requests (Maughan et al., 2021). Some SNs also reported impacts on their ability to carry out their usual (non-Covid-related) duties (Combe, 2020b). Despite these challenges, SNs indicated that their role in preparing for students' return to school and developing/   (Maughan et al., 2021;Robarge, 2021;Traut, 2020;Unknown, 2020b), providing staff with information and advice (Combe, 2020b;Lee et al., 2021;Traut, 2020;Various, 2020b), supporting management with data collection and usage (Hansen, 2021), supporting disinfection processes (Booher, 2020) and enacting quarantines or school closures (Combe, 2020b). SNs were 'on-call' for conversations regarding evolving state guidelines (Traut, 2020).
Lastly, SNs were involved in organizing new school-located Covid-19 vaccination events and required extensive peer and local authority collaboration (Park et al., 2021).
There were positive impacts of these collaborative efforts.
A broad increase in cooperation within the school health service was reported (Martinsson et al., 2021). Increased interaction with building administrators led to a greater appreciation of SNs and their role (Hansen, 2021) and partnerships with local health boards elevated their profile (Flaherty, 2020). SNs garnered a 'seat at the Executive Team table' (Combe, 2020a, p. 186) and strengthened relationships with public health officials (Fauteux, 2021). There was variability in support and working practices (i.e working from home) across schools and managers (Martinsson et al., 2021). Similarly, professional conflicts emerged between some SNs and senior decision-makers (Combe, 2020b;Sorg, 2020;Traut, 2020).

Innovation
Some SNs were directly involved in the development and implementation of new and innovative processes and tools, including IT systems such as password-secured enrollment portals, electronic health records and e-consent (Marrapese et al., 2021;White, 2021).
For CYP, these included an electronic pass system to control the flow of students on campus (Bullard et al., 2021), a triage flow chart (Lee et al., 2021), and a standardized student wellness form (

Research recommendations
The continued school health offer There is evidence (anecdotal, informal and empirical) of innovative practices developed and adopted by SNs to deliver routine school nursing services.
There is a paucity of empirical research exploring this topic.
There is a lack of geographic representation across the literature. While there is some evidence of innovative practices being adopted by SNs to deliver routine school nursing services, there is a lack of evaluation or review of these practices (for young people and their families as well as SNs).
Research is needed to explore which innovative aspects of routine school nursing practice could (and should) endure post-pandemic. Geographically focused research is needed due to the diversity of the SN role and healthcare provision globally.
To undertake evaluations (from SN and service user perspectives) of practices which may be used more widely and extensively in post-pandemic school nursing practice.
The expanded school health offer There is evidence (anecdotal, informal and empirical) of SNs taking on various broader public health responsibilities during the pandemic, undertaken alongside their routine duties.
There is a paucity of empirical research exploring this topic.
There is a lack of geographic representation across the literature. While there is some evidence of innovative practices being adopted by SNs to deliver expanded services (i.e. broader public health) it is not clear what aspects (if any) may be maintained in routine school nursing services.
Research is needed to explore what aspects of SNs' expanded role will (and should) endure post-pandemic.
were also developed to meet specific new needs, including the tracking and reporting of staff and student symptoms and quarantine release procedures (Barbee- Lee et al., 2021;Kunz et al., 2022;Traut, 2020), the provision of vaccine notifications and online text support services (White, 2021).
SNs also delivered regular ethical guidance to school-based colleagues about the confidentiality of student information shared electronically (Marrapese et al., 2021). SNs were also involved in making adaptations to document sharing (Fauteux, 2021), data sharing and the use of hotlines for schools to report to the district (Hansen, 2021).  et al., 2016). These issues are important to take into account when considering the longevity of SNs' digital health offer. While our findings provide a snapshot of service providers' and users' experiences of using virtual platforms during the pandemic, it is important that these mechanisms for service delivery are thoroughly evaluated before decisions are made regarding their continued implementation (Perakslis & Ginsburg, 2021).

| DISCUSS ION
SNs' ongoing communication and working relationships with their school-based colleagues and broader professional partners also changed during the pandemic. During a time where many CYP were increasingly vulnerable to deteriorating mental health (Panchal et al., 2021), exacerbation of existing physical health issues and problems at home (Cohodes et al., 2021),

Maughan and Luehr (2022) have drawn parallels between
Covid-19 and the 1918 Spanish Flu pandemic, noting that many of today's SN activities mirror practices from the early 20th century.
Yet global development, new technology and nurses' ever-increasing professional autonomy have meant that SNs were able to take on a leading public health role in this most recent global health crisis.
Though this undoubtedly brought new challenges to an already stretched workforce, the profession was also strengthened by the increased visibility and reach of their expertise. SNs were quick to embrace new ways of working and proactively adapted their practice to meet new needs, including contributions to the development of numerous innovative solutions that will likely endure post-pandemic. However, without adequate investment in staff and infrastructure, SNs' power to enact the changes envisioned by the WHO and UNESCO (2021b) and other global health authorities (NASN, n.d.; SAPHNA, 2021) will be limited.

| Strengths and limitations
Though we had hoped to capture a range of international literature, the majority (n = 23) of our included articles came from the USA, limiting the generalizability of our findings. This will be especially true for low-and middle-income countries where SN practice and coverage are more limited (or even non-existent) (see WHO & UNESCO, 2021a). Our findings are further limited by the nature of the data we retrieved. The fact that the majority of our included articles were opinion and commentary pieces meant that most data were anecdotal, impeding our ability to undertake a systematic review. However, our findings reflect the global attention afforded to SN practice during the pandemic, highlighting a significant literature gap and uncovering important avenues for future research. The authors of this review are currently undertaking follow-on research exploring SNs' experiences in more depth. By including grey literature we were able to capture a wider scope of evidence.
Our review was strengthened by its methodological rigor, including the comprehensive search strategy, screening and data extraction processes. Key expert stakeholders were actively involved throughout the process of developing, conducting and finalizing this review. Multiple researchers were involved in undertaking each of these processes, enhancing the reliability of our findings.

| CON CLUS ION
This scoping review presents global evidence describing how SNs' practices changed over the course of the Covid-19 pandemic. The pandemic accelerated SNs' need and/or ability to devise creative solutions to emerging problems. SN knowledge and skills came to the fore, enabling continued delivery of child-focused services alongside the additional demands of Covid-19. Many of these innovative practices could be useful post-pandemic. However, formal evaluation is needed to identify which practices may merit integration into routine practice. It is hoped that this review, together with other phases of this project and other research, will contribute to the discussion of innovative SN practices and the vital expert public health role of the SN.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.

PEER R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15504.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that supports the findings of this study are available in the article and/or supplementary material of this article.